Case Report An Unusual Knee Trauma: Combined Rupture …downloads.hindawi.com/journals/crior/2014/657296.pdf · Medial Collateral Ligament and Patellar Tendon ... A -y ear-old man

Case ReportAn Unusual Knee Trauma: Combined Rupture ofMedial Collateral Ligament and Patellar Tendon

T. De Baere, J. De Muylder, and A. Deltour

Kliniek Sint-Jan, Kruidtuinlaan 32, 1000 Brussel, Belgium

Correspondence should be addressed to T. De Baere; [email protected]

Received 12 May 2014; Accepted 5 August 2014; Published 18 August 2014

Academic Editor: John Nyland

Copyright © 2014 T. De Baere et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

We present the case of a combined lesion of the medial collateral ligament (MCL) and patellar tendon of the knee in a 45-year-old man, after a fall while skiing. Although there are numerous publications concerning associated tears of MCL and other kneeligaments, a combination ofMCL tear with a rupture of the patellar tendon is very rare. After a review of the literature and treatmentguidelines about these lesions, the clinical case is described and discussed. This knee trauma was treated with a transosseousreinsertion of the patellar tendon, which was reinforced by an allograft of fascia lata, followed by a direct suture of the MCL,which was reinforced with the lateral semitendinosus tendon.

1. Introduction

The MCL is the most frequently damaged ligamentousstabilizer of the knee. Injuries to the collateral ligamentsare defined into three degrees by the American MedicalAssociation [1]: first degree implies either a microscopictear or less than one-third of the ligament involved withoutchange in function. Second degree implies a macroscopictearing with intact fibers remaining (one-third to two-thirdsof the ligament involved), giving functional impairment andslight laxity on ligament testing. Third-degree injury impliesa complete tear of the ligament with marked instability onligament testing. Clinically these medial collateral ligamentinjuries are graded by joint line opening on valgus stresstesting with the knee in 30 degrees of flexion, compared tothe uninjured knee. An increase in opening of less than 5mmis a grade I tear, an increase in opening from 5 to 9mm is agrade II tear, and an increase in opening greater than 10mmis a grade III tear.These grade III tears imply complete tearingof the ligament [2].

MCL injuries do occur as isolated lesions or in combina-tion with damage to other ligamentous structures (meniscusand/or cruciate ligaments). For instance, Fetto found an80% incidence of combined ligament injury with grade IIIMCL tears [3].

There is a general consensus that treatment is nonop-erative for grade I and grade II tears of the MCL. Forgrade III lesions, however, there remains controversywhethertreatment should be conservative or surgical. Usually, isolatedgrade III tears are treated conservatively, but in associationwith injury to other knee ligaments, there is a tendency tosurgically treat the MCL lesion [2, 4, 5]. When surgicallytreated, usually a reconstruction with a semitendinosusallograft is used, a technique which was originally describedby Bosworth [6].

Patellar tendon ruptures usually occur in youngerpatients as a result of a violent eccentric contraction of theextensor mechanism of the knee. Degenerative processes ofthe tendon are often present before rupture and numerousauthors have indicated a history of pain before rupture[7]. Most of the ruptures occur at the inferior pole ofthe patella. There is a general consensus that these lesionsneed surgical treatment and results of surgical treatment areusually favorable [8].

We report the case of a 45-year-old man with a completetear of the MCL of the knee, combined with a tear of thepatellar tendon. In isolation, these lesions appear relativelyfrequently, but the originality of this case is in the combina-tion of both lesions. We did not find any report of a similar

Hindawi Publishing CorporationCase Reports in OrthopedicsVolume 2014, Article ID 657296, 4 pageshttp://dx.doi.org/10.1155/2014/657296

2 Case Reports in Orthopedics

case in the literature. Rae and Davies, in 1991, described acase of a young female with a combined lesion of anteriorcruciate ligament, medial collateral ligament, and patellartendon. They treated this lesion with a suture of the patellartendon and medial collateral ligament and reported a goodfunctional outcome [9].

2. Case Report

A 45-year-old man presented to our clinic with a left kneeinjury that had occurred a few days before while skiing. Hehad been immobilized in a brace at the local medical office.

Clinical examination showedmarked swelling of the kneejoint, with pain at passive mobilization and restricted activemotion: 40∘ of active flexion and an inability to activelyextend the knee. Weight-bearing was hardly possible. Therewas an obvious gap at the level of the insertion of the patellartendon on the lower pole of the patella. Testing of the MCLcompared to the healthy side showed>10mmwidening of themedial joint line with valgus stress in 30∘ of flexion as well asin full extension.There was no clinical evidence of instabilityof the other knee ligaments.

The X-ray of the injured knee showed a superior migra-tion of the patella compared to its usual position (Figure 1).An MRI-scan confirmed the clinical suspicion of a completetear of the MCL next to its proximal insertion on the medialfemoral condyle, as well as a complete rupture of the patellartendon at the level of its insertion on the lower pole of thepatella. There were no lesions of the cruciate ligaments andmenisci (Figure 2).

The medical history revealed lower back pain due to aherniated disc, which had been treated conservatively. Thepatient also reported some pain episodes at the level of theleft patellar tendon while jogging in the past. No specifictreatment was prescribed for these pains.

Our patient was operated on under epidural anesthesia 5days after his accident. Clinical examination under anaesthe-sia confirmed once again the complete instability of the MCLwith valgus stress without laxity in the other plains ofmotion.

At first, we approached the patellar tendon through ananterior longitudinal midline incision. After debridement ofthe tendinous tissue at the level of the tear, a Krackow-stitchwas placed in the patellar tendon distally to its tear. The twoloops of this stitch were passed through two bony tunnelsin the patella and sutured to each other at the proximalpole of the patella. At the level of the tear, the transosseousreinsertion was reinforced by a running suture of a 3/0 wire.As there was a history of pain at the patellar tendon, wedecided to reinforce the reinsertion of the tendon with anallograft of fascia lata, which was sutured directly to thetendinous tissue with absorbable stitches.

The tear of the MCL was approached via an obliquemedial incision. At first we performed a direct suture whichwas reinforced with an autograft of the homolateral semi-tendinosus tendon. The semitendinosus was isolated withan open stripper, taking care to preserve its distal insertionon the tibia. After suturing it to the MCL, the autograftwas fixed proximally with a staple at the level of the medial

Figure 1

Figure 2

femoral condyle and distally with a direct suture to its originalinsertion in order to obtain a double-loop reinforcement.Thestaple fixation was done in a position of 30∘ knee flexion andslight varus.

Postoperatively the knee was immobilized in 10∘ offlexion in a synthetic plaster cast with partial weight-bearingallowed. After 3 weeks the knee was placed in a brace withprogressive flexion: 30∘ the first week, 60∘ the second week,and 90∘ the last week. After 6 weeks the brace was removedand complete flexion allowed. A rehabilitation programmewith progressive mobilization, proprioceptive training, andmuscle strengthening exercises was started.

Clinical control 3 months after the operation showeda limitation of flexion of 20∘ compared to the other side.There was no swelling of the knee but evident atrophy ofthe quadriceps muscle without limitation of active extension.Mediolateral stability testing showed no residual valgusinstability. A bilateral X-ray of the knee showednormal heightof the patella.

At 6 months, full motion was recovered and the patienthad returned to normal daily life and recreational sportsactivities (cycling, fitness). Due to discomfort at the level of

Case Reports in Orthopedics 3

the medial femoral condyle, the staple fixing the semitendi-nosus autograft was removed at 9 months. After this removal,no medial instability occurred. At final follow-up 18 monthsafter the injury, the patient was symptom-free and he hadreturned to skiing, protecting his knee with a brace.

3. Discussion

In the literature, no descriptions of combined lesion of MCLand patellar tendon are found. In contrast, the association of atear of theMCL, combined with a tear of the anterior cruciateligament, is well known. In these cases there is a tendencytowards surgical treatment of severe MCL lesions.

In a comparative study between conservative and surgicaltreatment for isolated grade III MCL sprains, Indelicatofound comparable results with either treatment [10]. Reiderfollowed 35 patients with an isolated grade III MCL spraintreated with early functional rehabilitation for 5 years andfound comparable results to those achieved by surgery inother studies [11]. Jones et al. reported early return tosports in high school football players with isolated grade IIIMCL injuries treated nonoperatively [12]. Other researchersconfirm these results for as long as there is no associatedlesion of the anterior cruciate ligament and results withoperative treatment have been shown to be inferior tononoperative treatment. Stiffness is known to be the mostcommon complication of surgical treatment of isolated gradeIII MCL sprains [2].

In a literature study, Kovachevich et al. [13] reviewedthe treatment of MCL lesions in dislocated or so-calledmultiligament injured knees. They conclude that, in theseseverely traumatized knees, a complete tear of the MCL has apoor healing capacity left on his own and surgical treatment isindicated. Good results are obtained with either direct repairof the MCL or reconstruction with semitendinosus autograftor synthetical graft.

Merritt and Wahl [14] presented a study on the treat-ment of 138 dislocated and≪multiligament injured≫ knees.Surgery of these knees is scheduled 2 to 3 weeks after theinitial injury, and decision to surgically treat theMCL ismadeif during surgery an opening 8 to 10mm is found in themedialcompartment with valgus stress in 30∘ of flexion. TheseMCL lesions are then treated using the modified Bosworthtechnique, using the semitendinosus tendon of which thedistal insertion is left in place.

Gwathmey et al. [15] presented the decision algorithmof the Virginia University in multiligament injured knees. Ifthey decide to operate on a torn MCL, their technique is adirect suture, reinforced by a modified Bosworth techniqueor reconstruction by means of an allograft. In case of themodified Bosworth technique, they prefer harvesting thesemitendinosus tendon. In case of an allograft, they also usea semitendinosus.

Futch et al. [16] reported on a case of a combined anteriorcruciate ligament and patellar tendon rupture in a youngathlete. This knee was treated with a reconstruction of theanterior cruciate ligament and a suture of the patellar tendon,which was augmented with a patellar tendon allograft. In

their opinion, the reinforcement with a patellar tendonallograft biomechanically protects the suture of the tendonthrough reduction of tension, allowing earlier rehabilitation.

In our case, the combination of a MCL tear with a tearof the patellar tendon is strictly not to be considered asmultiligament injured knee. During the surgical interventionthat was necessary for the tear of the patellar tendon, thepersistent valgus instability justified surgical treatment of theMCL tear. Because our patient already suffered from pain atthe level of the patellar tendon before his injury, we decidedto use a fascia lata allograft to reinforce the patellar tendonsuture. This also allowed for early mobilization.

4. Conclusion

To our knowledge, this is the first report of a combined tearof the MCL and the patellar tendon. The surgical treatment,postoperative rehabilitation, and literature on combined kneelesions are discussed.

Conflict of Interests

The authors declare that there is no conflict of interestsregarding the publication of this paper.

References

[1] American Medical Association Committee on the MedicalAspects of Sports, Standard Nomenclature of Athletic Injuries,American Medical Association, Chicago, Ill, USA, 1966.

[2] R. W. Bucholz, “Injuries to the collateral ligaments of the knee,”in Rockwood and Green’s Fractures in Adults, vol. 2, pp. 1884–1896, Lippincott Williams &Wilkins, 5th edition, 2001.

[3] J. F. Fetto and J. L. Marshall, “Medial collateral ligament injuriesof the knee,”Clinical Orthopaedics and Related Research, no. 132,pp. 206–218, 1978.

[4] R. G. Miyamoto, J. A. Bosco, and O. H. Sherman, “Treatmentof medial collateral ligament injuries,” Journal of the AmericanAcademy of Orthopaedic Surgeons, vol. 17, no. 3, pp. 152–161,2009.

[5] S. Terry Canale, Ed., Campbell’s Operative Orthopaedics, vol. 2of Knee Injuries, Chapter 29, 9th edition, 1998, edited by.

[6] D. M. Bosworth, “Transplantation of the semitendinosus forrepair of laceration of medial collateral ligament of the knee.,”The Journal of Bone and Joint Surgery A, vol. 34, no. 1, pp. 196–202, 1952.

[7] “Traumatic disorders,” in Campbell’s Operative Orthopaedics, S.Terry Canale, Ed., vol. 2, chapter 32, p. 1423, 9th edition, 1998.

[8] “Patellar tendon rupture,” in Rockwood and Green’s Fractures inAdults, vol. 2, pp. 1858–1863, Lippincott, Williams and Wilkins,5th edition, 2001.

[9] P. J. Rae and D. R. A. Davies, “Simultaneous rupture of theligamentum patellae, medial collateral, and anterior cruciateligaments: a case report,” American Journal of Sports Medicine,vol. 19, no. 5, pp. 529–530, 1991.

[10] P. A. Indelicato, “Non-operative treatment of complete tears ofthe medial collateral ligament of the knee,” Journal of Bone andJoint Surgery, vol. 65, no. 3, pp. 323–329, 1983.

[11] B. Reider, M. R. Sathy, J. Talkington, N. Blyznak, and S. Kollias,“Treatment of isolated medical collateral ligament injuries in

4 Case Reports in Orthopedics

athletes with early functional rehabilitation. A five-year follow-up study,”The American Journal of Sports Medicine, vol. 22, no.4, pp. 470–477, 1994.

[12] R. E. Jones, M. B. Henley, and P. Francis, “Nonoperativemanagement of isolated grade III collateral ligament injury inhigh school football players,” Clinical Orthopaedics and RelatedResearch, vol. 213, pp. 137–140, 1986.

[13] R. Kovachevich, J. P. Shah, A.M.Arens,M. J. Stuart, D. L.Dahm,and B. A. Levy, “Operative management of the medial collateralligament in the multi-ligament injured knee: an evidence-based systematic review,” Knee Surgery, Sports Traumatology,Arthroscopy, vol. 17, no. 7, pp. 823–829, 2009.

[14] A. L. Merritt and C. J. Wahl, “Rationale and treatment ofmultiple-ligament injured knees: the Seattle perspective,”Oper-ative Techniques in Sports Medicine, vol. 19, no. 1, pp. 51–72, 2011.

[15] F. W. Gwathmey, D. A. Shafique, and M. D. Miller, “Ourapproach to the management ot the multiple-ligament kneeinjury,” Operative Techniques in Sports Medicine, vol. 18, no. 4,pp. 235–244, 2010.

[16] L. A. Futch, W. P. Garth, G. J. Folsom, and W. K. Ogard, “Acuterupture of the anterior cruciate ligament and patellar tendon ina collegiate athlete,” Arthroscopy, vol. 23, no. 1, pp. 112.e1–112.e4,2007.

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Case Report An Unusual Knee Trauma: Combined Rupture …downloads.hindawi.com/journals/crior/2014/657296.pdf · Medial Collateral Ligament and Patellar Tendon ... A -y ear-old man